Efficacy and safety of catheter ablation for atrial fibrillation in patients with cancer

Background

Atrial fibrillation (AF) is the most common arrhythmia in patients with cancer. Management of AF in patients with cancer poses unique challenges. Long-term use of antiarrhythmic drug (AAD) therapy lacks evidence of efficacy in this population and poses risk of drug interactions. Catheter ablation is a well-established treatment modality for AAD resistant symptomatic AF and in patients with heart failure. Nevertheless, the effectiveness and safety of catheter ablation in patients with cancer is not well established.

Method

We retrospectively analyzed consecutive patients who underwent catheter ablation for AF, with either history of cancer (other than non-melanoma skin cancer) within 5-years prior or exposure to systemic anthracycline and/or thoracic radiation therapy at any time.

Results

The study included 162 patients. The mean age was 65.5 (26–84 years) years and 50% were female. Overall 133 (82%) patients had freedom from AF at 12 months following ablation. Of these 74 (54%) required post-ablation AAD, 18 (13.5%) required another ablation within the first 12 months and 9 (6.7%) required both AAD and a second ablation to maintain sinus rhythm. There were 14 adverse events (8.6%); 5 access site and 4 non-access site bleeding, 2 strokes, 2 cardiac tamponade and 1 pulmonary vein stenosis with ≈1% serious complications.

Conclusion

The success of catheter ablation for AF and the incidence of procedure related complications in patients with a history of recent cancer or prior exposure to cardiotoxic therapies are similar to that reported in patients without a history of cancer and hence if needed, it should be considered in select patients.

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Dr. S Ganatra is supported by Lahey Physician Research Stipend Program.

Cardiovascular effects of chimeric antigen receptor t-cell therapy for refractory or relapsed non-hodgkin lymphoma

Purpose

Cardiovascular complications of chimeric antigen receptor T-cell (CAR T-cell) therapy are poorly understood. We examined the incidence, predictors and impact of new or worsening cardiomyopathy in patients undergoing CAR T-cell therapy.

Methods

All patients with refractory or relapsed non-Hodgkin's lymphoma, undergoing CAR T-cell therapy at collaborative institutes underwent serial echocardiograms at baseline and within 7 days after developing high-grade cytokine release syndrome (CRS), and were followed for all-cause mortality. New or worsening cardiomyopathy was defined as a reduction in left ventricular ejection fraction (LVEF) >10% from baseline to <50% during the index hospitalization.

Results

Among 187 consecutive CAR T-cell therapy patients, 116 (50 Grade ≤1 CRS, 66 Grade ≥2 CRS) had >1 echocardiogram performed and were included in this analysis. The median age was 63 (range 19–80) years, 42% were women, 91% were Caucasian. A total of 12 (10.3%) patients developed new or worsening cardiomyopathy with a decline in LVEF from 58±6% to 36±7% within a median of 12.5 (range 2–24) days of CAR T-cell infusion. In multivariable analyses, older age, prior stem cell transplantation, baseline angiotensin-converting enzyme inhibitor use and CRS grade ≥2 were associated with the development of cardiomyopathy. Patients who developed cardiomyopathy were more likely to require vasopressor support (p=0.004) and mechanical ventilation (p=0.014). LVEF improved in 9/12 (75%) patients. CAR T-cell associated cardiomyopathy did not impact overall mortality or cancer response to CAR-T cell therapy.

Conclusions

Patients undergoing CAR T-cell therapy are at risk of developing cardiomyopathy and hemodynamic instability. Pre-CAR T-cell therapy cardiovascular risk stratification and echocardiogram surveillance during therapy should be considered for prompt identification and mitigation of cardiac complications.

Predictors of Cardiomyopathy Development

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Anju Nohria, MD is supported by the Gelb Master Clinician Award at Brigham and Women's Hospital.

Management of cardiac disease in cancer patients throughout oncological treatment: ESMO consensus recommendations

Cancer and cardiovascular (CV) disease are the most prevalent diseases in the developed world. Evidence increasingly shows that these conditions are interlinked through common risk factors, coincident in an ageing population, and are connected biologically through some deleterious effects of anticancer treatment on CV health. Anticancer therapies can cause a wide spectrum of short- and long-term cardiotoxic effects. An explosion of novel cancer therapies has revolutionised this field and dramatically altered cancer prognosis. Nevertheless, these new therapies have introduced unexpected CV complications beyond heart failure. Common CV toxicities related to cancer therapy are defined, along with suggested strategies for prevention, detection and treatment. This ESMO consensus article proposes to define CV toxicities related to cancer or its therapies and provide guidance regarding prevention, screening, monitoring and treatment of CV toxicity. The majority of anticancer therapies are associated with some CV toxicity, ranging from asymptomatic and transient to more clinically significant and long-lasting cardiac events. It is critical however, that concerns about potential CV damage resulting from anticancer therapies should be weighed against the potential benefits of cancer therapy, including benefits in overall survival. CV disease in patients with cancer is complex and treatment needs to be individualised. The scope of cardio-oncology is wide and includes prevention, detection, monitoring and treatment of CV toxicity related to cancer therapy, and also ensuring the safe development of future novel cancer treatments that minimise the impact on CV health. It is anticipated that the management strategies discussed herein will be suitable for the majority of patients. Nonetheless, the clinical judgment of physicians remains extremely important; hence, when using these best clinical practices to inform treatment options and decisions, practitioners should also consider the individual circumstances of their patients on a case-by-case basis.

Digital Imaging Capability for Caries Detection

The objective of this study was to identify the diagnostic capability of photostimulable phosphor plates (PSPs) and direct digital sensors (DDSs) in the detection of interproximal caries. Studies were identified that evaluated the diagnostic capability of PSPs and DDSs in detecting interproximal caries in human teeth, in both dentin and enamel. Histologic sections were the gold standard. This systematic review searched several electronic databases. In addition, Google Scholar and reference lists of the finally included studies were screened. QUADAS-2 was applied to evaluate the risk of bias among included studies. Six studies were finally included; 4 of which were considered homogeneous enough to conduct a meta-analysis. The meta-analysis evaluated 668 interproximal human tooth surfaces. All studies used extracted human teeth ranging from no caries present to caries into dentin. Each tooth was radiographed by both PSP and DDS technologies and then submitted for histologic analysis as the gold standard. Meta-analysis showed that intraoral digital imaging is of high specificity but low sensitivity in the detection of interproximal caries. The sensitivity and specificity for different studies with PSPs varied substantially from 15% to 54% and from 84% to 100%, respectively. Direct sensor analysis sensitivity and specificity ranged from 16% to 56% and from 90% to 100%, respectively. Newer PSP and DDS technologies had statistically significant higher sensitivities, yet the differences in diagnostic capabilities between the older and newer technologies were clinically insignificant. Both digital systems were excellent in identifying surfaces without caries (specificity) but were not sensitive enough to reliably identify interproximal surfaces with caries. Clinicians must therefore remain vigilant in performing a careful clinical examination and other diagnostic tests rather than relying solely on radiographic imaging to diagnose interproximal caries.

Knowledge Transfer Statement: This study will help clinicians make an evidence-based decision when deciding which digital radiography system to use when evaluating interproximal caries. Time, patient radiation safety, cost, and image quality are factors to be considered. The performance of the different available digital imaging systems was compared with the current gold standard—a histologic analysis—via meta-analysis.

Histology near periodontitis osteoclasts

Histologic evaluation of periodontal tissues generally has included only areas adjacent to the gingival crevice, without knowledge or quantitation of alveolar crest osteoclastic (periodontitis) activity and infiltrate. The purpose of this study was to use human autopsy material to quantitate collagen and cell types adjacent to presumed periodontitis activity and quiescence, each in the same individual. Thirteen subjects contributed 4 sites each, 2 exhibiting alveolar crest periosteal osteoclasts in resorption lacunae/periodontitis activity (OC/PA) and 2 with no osteoclasts or resorption lacunae/ periodontal quiescence (NOC/PQ). Tissue and cell morphotypes were quantitated by 2 evaluators at 100 intersects in 0.06 mm2 fields progressing from the alveolar crest toward the gingival crevice. Cell morphotypes/tissue components were compared between groups and fields using a general linear model with repeated measures. OC/PA fields adjacent to the alveolar crest contained significantly more intersects with macrophage-like cells (10.7+/-1.1 versus 5.3+/-0.6%, P=0.0003), lymphocytes (4.6+/-1.1 versus 0.7+/-0.2%, P=0.0013), plasma cells (13.3+/-2.7 versus 2.1+/-0.6%, P=0.0004), and less with collagen (48.9+/-3.5 versus 75.0+/-2.0%, P=0.0001) than NOC/PQ fields. Numbers of lymphocytes and plasma cells increased (P=0.0006 and P=0.0002, respectively), and fibroblasts and collagen decreased (P=0.0024 and P=0.0001, respectively) in fields up to 1 mm closer to the gingival crevice. However, apparent osteoclastic activity in periodontitis subjects is associated with a significant inflammatory cell infiltrate, especially macrophages and plasma cells.

Studies on calcium absorption from milk using a double-label stable isotope technique

Calcium absorption was measured in ten male volunteers from skimmed milk, Ca-enriched skimmed milk or watercress (Nasturtium officinale) soup. The foods were labelled extrinsically with 30 mg 44Ca. Shortly after consuming the labelled meal, each subject was given an intravenous injection of 3 mg 42Ca. Fractional absorption from the oral dose was determined from plasma and urine samples collected 24-72 h later, using fast atom bombardment mass spectrometry to measure isotope ratios. The values for urine and plasma were in good agreement. Mean percentage absorption was 45.5 (SEM 1.9)% from the skimmed milk, 35.7 (SEM 4.7)% from the Ca-enriched milk and 27.4 (SEM 1.9)% from the watercress soup. The effect of consuming 568 ml (1 pint) Ca-enriched milk each day for 4 weeks on the efficiency of absorption of Ca was studied. Although there was no statistically significant difference between Ca absorption before and after the supplementation period, the results were considered to be somewhat inconclusive due to the small number of subjects and wide individual variation in Ca absorption.

Human fertilization by micro-injection of immotile spermatozoa

Microfertilization of human oocytes with spermatozoa from a man with immotile cilia syndrome is reported, confirming a preliminary investigation where a zona-free donor oocyte was fertilized with spermatozoa from the same patient. Oocytes from his spouse were obtained by laparoscopy after routine stimulation with clomiphene citrate, human menopausal and chorionic gonadotrophins, and were cultured for 4-6 h in Whittingham's T6 medium, supplemented with 10% of her serum. The spermatozoa were washed and processed in the same medium and capacitated for 6-8 h before micromanipulation. Three of five mature oocytes were fertilized by micro-injection of a single immotile spermatozoon into the perivitelline space. One oocyte produced a two-pronuclear ovum assessed 19 h after injection, while the other two produced 2-cell embryos with blastomeres of equal size, 22 h after injection. These embryos cleaved to 3-8-cell stages in culture before embryo replacement. No pregnancy resulted from embryo transfer. The results conclusively demonstrate that human oocytes can be fertilized successfully with immotile spermatozoa by micro-injection and the work has profound implications in the treatment of severe male infertility.